Coronavirus (COVID-19): fertility treatment - plans for restarting treatment - framework

4 Working together for Scotland

4.1 Equity of treatment

In order to provide equitable services across Scotland we will prioritise NHS funded treatments across all 4 centres to treat NHS funded patients. There will be no transfer of funding to private centres, even if there was a request for the possibility of earlier treatment. All centres will maximise their capacity by working efficiently to get through waiting lists. However, this will need to be done safely and cautiously taking into considerations of the principles outlined in section 2.

4.2 Communication

At all times communication will be key in managing this unprecedented clinical situation. We will communicate between clinics, within clinics, with primary care colleagues, patients and professional organisations such as HFEA, BFS, ARCS as well as colleagues in other parts of the world, who have already restarted treatments. We will work closely with Fertility network UK (the UK's leading fertility patient organisation) throughout our discussion.

Weekly meetings are booked with representation from Aberdeen, Dundee, Edinburgh and Glasgow.

4.3 Prioritisation of treatments

We are aware that waiting lists will be long and many patients would wish to have treatment as soon as possible. All clinics have been keeping lists of those who could not complete treatment and those who could not start, in addition to keeping a list of those on waiting list.

It is uncertain at present times as to whether we should treat everyone in order of waiting list or prioritise those with low ovarian reserve or start with those who have embryos frozen. Any decisions will need to take in considerations as outlined in section 2.

During the meeting on 28/04/20, the group agreed that there were benefits in starting treatments for those with embryos frozen as:

• This does not pose risk of ovarian hyperstimulation (which may need unpredictable hospital admission and sometimes multiorgan dysfunction and ITU admission)
• It is simple, safe relatively non-invasive treatment and easy to start and stop, if we need to, in event of second wave of COVID-19 and further lockdown.
• It allows for all staff to adapt to new ways of working and refresh skills
• It does not require sedation, oxygen or anaesthetists, who may be required elsewhere

Evidence up until now suggest that COVID-19 does not have significant impact on pregnancy. However, we have to be mindful that this is new disease and evidence is continuously evolving, both in terms of data relating to disease symptoms, impact on body systems and long term sequelae. We will continue to monitor evidence on pregnancy and COVID19 as it is evolving⁷. Pragmatic decision based on robust clinical data will be made and modified as clinical and scientific data are available.

In making decisions we will be conscious that fertility treatments involve multiple appointments at hospital i.e. travel, although travel is for medical need but poses risk in current climate. This poses real risk to those who have to travel long distance as treatments are provided in Aberdeen, Dundee, Edinburgh and Glasgow only. At all times considerations will be given to equity, parity, as well as logistics of delivering a safe service alongside patient wishes.

We are aware of the potential need to suddenly stop treatments in the event of a second wave.

Diagnostic services may be started first (e.g. semen analysis and Hydro-contrast sono-salphingography) followed by treatments. This will give a chance for some of the process to be rehearsed and modified before actual treatment start.

We will apply particular caution to patients with underlying medical problems whose co-morbidity places them at a higher risk of complications in the event of contracting coronavirus infection. This includes patients with hypertension, diabetes, severe asthma and those receiving immunosuppressive medication. It may be appropriate for such patients to delay conception until epidemiological evidence shows a sustained reduction in the community spread of the infection. These will be discussed as part of multidisciplinary group for individualised decision making.

If a patient had COVID -19 which required respiratory support, we will liaise with relevant clinicians. Treatment will only be commenced once a favourable assessment is obtained.

We will work with evolving scientific and medical evidence to prioritise fertility treatment and develop a joint approach which will be transparent and uniform across Scotland.

A Road map has been agreed (Appendix 4) after multiple discussion within the group.

4.4 Access to NHS treatment

The group is aware that there are patients who could not start treatment despite being near or at the top of the waiting list, others could not complete or initiate a subsequent cycle of treatment, while others are waiting for initial referral.

As one of the main access criteria to NHS treatment is based on age of female partner, many fear losing access to NHS funded treatment due to delays imposed by COVID-19, and others may not be able to access their full potential entitlement.

In order to be fair, equitable and ethical, it was agreed that those who are already on waiting list will have this time paused and extra months from 17/03/20 – to whenever the clinics can open (and contact individual patient to offer fresh IVF treatments) will be added to their access for their full treatment journey, as long as other NHS criteria of are met. This is the case both for couples where the partner being treated is under 40 and couples where the partner being treated is aged between 40 and 42.

All those who are referred from primary and secondary care during the pandemic time ( 01/03/20 - 31/08/2020), will have 6 months added to age eligibility criteria, so that couples, especially where the woman/partner having treatment is older, are not disadvantaged in accessing either one full cycle or three full cycles, if it is clinically appropriate to do so. This takes into consideration that there have been delays in referrals for treatment, both at primary and secondary care. We are also aware that patients have not approached GPs for referral due to the pandemic.

However, all clinics will be working with remote consultations to address these referrals as soon as it is feasible and safe.

Frequently asked questions (FAQs) to patients, which will be put on webpages of all clinics and Fertility Network UK, to provide clarity regarding management of the waiting list so that is transparent and clear.